A failed perioperative nursing journal club: Reflections on A failed perioperative nursing journal club: Reflections on mistakes made, and lessons learned

My great idea was to start a perioperative nursing journal club in my workplace, a small four-theatre complex in a busy rural public hospital in NSW. It failed. As clinicians, we are usually more than happy to share our successes, but less ready to share our failures. The purpose of this paper is to share the experience of this failure, the mistakes I made, and the lessons I learned. It will discuss learning from our mistakes, the reality of evidence-based practice, journal clubs: barriers and requirements for success, and my own experience and reflections on attempting to start a perioperative nursing journal club.


Introduction
My great idea was to start a perioperative nursing journal club in my workplace, a small fourtheatre complex in a busy rural public hospital in NSW. It failed. As clinicians, we are usually more than happy to share our successes, but less ready to share our failures. The purpose of this paper is to share the experience of this failure, the mistakes I made, and the lessons I learned. It will discuss learning from our mistakes, the reality of evidence-based practice, journal clubs: barriers and requirements for success, and my own experience and reflections on attempting to start a perioperative nursing journal club.

Learning from mistakes
Nurses well understand the need to learn from our mistakes. What nurse hasn't gone home troubled by the things we missed, or didn't do, unable to forget the things that went badly wrong? Learning from our mistakes is a well-supported theoretical concept, including Piaget's theory of cognitive development assimilation and accommodation 1 , adult learning principles 2 , social learning theory 3 , and critical reflection in nursing 4 . Caring about mistakes and failures is an important part of improvement 5 . By owning my mistakes, and reflecting on them, I hope to transform my own understanding of my workplace, my colleagues and myself, and to assist others to avoid making similar mistakes.

Evidence-based practice
Professional accountability requires Australian perioperative nurses to practise within an evidence-based framework (Australian Nursing and Midwifery Council) 6 . Evidence-based practice (EBP) is the current catchcry in nursing 7 , regarded as the "gold standard" by many 8 . It is defined as a "decision making process based on high quality research results instead of less reliable expert opinion" 9 .
The term EBP arose in the early 1990s, and has enjoyed increasing prominence and emphasis in the nursing literature. Despite this popularity, it is still referred to as a "new" approach 9-11 .
Many sources have questioned the issue of the reality of limited utility of EBP and discussed barriers to applying EBP in the clinical workplace [12][13][14][15] . These include competing clinical priorities/ time, appraisal skill deficits, and information overload 14,15 .
Despite the ready availability of numerous EBP recommendations sources, such as the Cochrane Collaboration, Johanna Briggs Institute and Up-To-Date, many clinical nurses do not access these sites. Pearson questions the utility of scientific nursing journals to nursing practice, suggesting that availability of high-level evidence is of no use if it is not being accessed and understood by clinical nurses 16 .
Sadly, it appears that many clinical nurses are restricted in their ability to perform EBP as they do not have the necessary skills to access, understand and critique the research findings available. It could be argued that the evidence of EBP in nursing is limited on the clinical floor. This was certainly the case in our journal club, with the majority of nurses who attended being unaware of the existence of this type of information, and expressing confusion with much of the meaning and language used and critique skills, promote research awareness, reduce the theorypractice gap and promote EBP [26][27][28] . Journal clubs have also been linked to the professional empowerment of nurses 29 , and generating a positive research culture 21 .

Journal club requirements for success
The literature does provide a number of requirements for successful nursing journal clubs. These include: • supportive organisational structures 30

Journal club barriers
Barriers to nursing journal club success include lack of skill, organisational barriers, such as absence of research culture and training opportunities 29 , and a lack of incentives for nurses to participate 31 .

Lack of skills
Despite the decade-long professional responsibility for registered nurses to use EBP, it is an unfortunate reality that many nurses still lack education and exposure to research, and have rudimentary research critique skills 31,32 . Although nurses support the concept of EBP, the reality is that many Australian nurses have a serious lack of proficiency in this area 6 , incredibly low levels of support for research 33 , and indifference and suspicion towards EBP in the workplace 34 . Although this is clearly not true of all Australian nurses, a lack of research skill and ability amongst some colleagues is a concept that many would identify with. This was certainly the case for our small group, many of whom had never undertaken any tertiary education at all. Those without a tertiary education background appeared overwhelmed and expressed confusion when dealing with the theoretical and technical aspects of journal papers, although it must be noted that they became much more comfortable when relating the topic of the article back to our own workplace and clinical practice.

Lack of research culture
The lack of a positive institutional research culture is a significant barrier to journal clubs [34][35][36] . As a relatively small rural hospital, we have an extremely limited research culture, despite having affiliations with two universities. There is no visible infrastructure to support a research-based culture. In-house education is entirely clinical in nature, predominantly focusing on mandatory education for accreditation, and does not include any research skill development.
There is no official research nurse role in the workplace, and there is limited awareness of any projects that may be undertaken by individuals. A poor, fragmented research culture such as this is characterised as small, separate and unfocused 37 .

Lack of time
Most perioperative nurses are too busy trying to complete their daily case list, without adding the extra activities required to develop and use the skills necessary for EBP. As a result, even those with tertiary education or experience in this area find our existing appraisal skills in the research journal articles discussed.
Despite the professional expectation of EBP, many nurses remain poorly prepared to access, assess and implement available research into their clinical practice 17 . It is ironic and notable that there is repetition in many of the barriers to both EBP and nursing journal clubs 8,18 .

Journal club background History
Journal clubs have been used by medicine as a way of sharing knowledge and keeping abreast of the literature for over 100 years [19][20][21] .
The nursing journal club is far less prolific, and it is simplistic and perhaps inappropriate to simply transpose the medical literature on journal clubs to nursing 22 .
Journal clubs for nurses have moved thorough several phases. In the 1980s, nursing journal clubs were an additional, supplementary education for students and nurses to keep up to date. In the 1990s, they focused more sharply on nursing research activities, while today they are predominantly driven by the need to evaluate research and implement its use in practice, as required by EBP 23 .
The sheer volume of research produced is daunting 9,24 . In Australia in 1992, there was only one refereed nursing journal 7

Lack of money
The prevailing environment is one of fiscal constraint, with most perioperative nurses familiar with trying to provide a high standard of care for increasingly more people, with fewer resources. It is an unfortunate reality that economic rationalism dominates the healthcare landscape, increasingly penetrating the clinical world 38 It is ironic, and bittersweet, that after I had given up, a number of staff attended an OTA education session/meeting, and mentioned to me they had proudly told others about our wonderful nursing journal club. A further and more painful occurrence came when my NUM mentioned she had told others at a managers meeting who were being told of the great new idea of a nursing journal club for ICU, that "We have had one of those for ages". It was disappointing, and perhaps telling, that she did not even realise that our journal club had collapsed due to staff being unable to attend. I felt that while perhaps management liked the idea of having a nursing journal club, they didn't prioritise it, and liked the idea of actively supporting and funding it in the form of time and money even less.

Mistakes? I made a few! 48
In reflecting on this experience, I easily identified a number of mistakes. These include: • I didn't get support or permission from anyone. I just did it.
• Even though I had initially recognised the research knowledge gap, I failed to recognise its depth or the hurdles such a gap would present. I had thought to be able to introduce staff to some basic critique concepts, and assist them to develop skills as we went. It was a mistake to attempt to share knowledge gained over a number of years in a short time.
• I didn't really canvas what the other members of the group wanted to get out of the nursing journal club. I imposed my own ideas and expectations without considering their expectations and capabilities. It is essential to ensure the journal club experience meets the needs of the group 31 . I also didn't get written feedback and evaluation of the journal club experience as it progressed. This meant I didn't find out what was wrong for them, and didn't alter the experience or content to meet their needs.
• I gave up. I allowed constraints other than my colleagues' interest and my own ability to stop my efforts to keep with the perioperative nursing journal club going.

Lessons learned
In order to "design and maintain a stimulating, educational and sustainable journal club" 20 , I would make a number of recommendations based on my experience.
• Be better prepared. Undertake an in-depth review of the literature about journal clubs before trying to start one.  49 . I didn't give myself the opportunity to benefit from the positive, collaborative benefits of the knowledge, skill and support of others that could have made the crucial difference between success and failure for the journal club.
• Evaluate satisfaction and the group's overall perceptions of the journal club. This could be done informally during a meeting, or by written feedback and evaluation. Be prepared to change the focus of the group to meet the group's needs 31 .
• Expect barriers and problems. Challenges will always exist in nursing. As perioperative nurses, we are well acquainted with troubleshooting and problem solving unexpected complications. We do this by focusing on the solution, rather than being stuck on the problem itself. Barriers to ongoing education and professional development in nursing are well recognised 50 , and were certainly not specific to our journal club group.
• Don't give up. I became disheartened and didn't seek support or assistance. This was perhaps my biggest mistake, and was nobody's choice except my own.

Conclusion
While my experience of starting a nursing journal club was a failure, I still felt that a number of important positives arose that made it worthwhile. Nursing staff in this unit were interested in research, and curious about learning more about it. They were aware of their need to practise from an evidence base, and enjoyed discussing how their own current practice compared to journal article topics. Even though critique was limited, discussion was generated about the research topics (if not the quality of the research itself).
In essence, I tried to do too much with too little. Too little knowledge, too little preparation, too little education, too little support and too few resources. When viewed from this perspective, it is not surprising that the group failed. Nurses need paid time away from clinical practice to develop and nurture their ability to access, critique and apply research to their own clinical practice. Don't give up, as challenges will always be present in the real and practical clinical world. The mistakes, lessons and reflection shared here can make our next attempt to start a journal club stronger, more realistic and better grounded, and better positioned for success. I would urge you to give it a go in your own workplace.

Implications for perioperative nursing practice
Despite professional acceptance of EBP, significant gaps still exist in the ability of clinical nurses to access, assess and implement nursing research findings into our everyday practice. As a profession we need to actively pursue skills and education to enable us to do more than pay lip service to EBP. Despite my own problems in establishing one, I still believe a nursing journal club is still one of the best ways to start this process.